Reinforcing the management of type 1 gastric esophageal varices

Abstract

Variceal bleed represents an important complication of cirrhosis, with its presence reflecting the severity of liver disease. Gastric varices, though less frequently seen than esophageal varices, present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality. Based upon the Sarin classification, GOV1 is the most common subtype of gastric varices seen in clinical practice.

Key Words: Gastric varices; Sarin classification; Gastroesophageal varices; Cyanoacrylate; Endoscopic variceal ligation; Trans jugular intrahepatic portosystemic shunt

Core Tip: Management of gastric varices can be challenging, with a correct diagnosis being of paramount importance in order to ensure that the correct treatment is given.

TO THE EDITOR

Gastric varices (GV) though less frequently seen as compared to esophageal varices (EV), account for 20% of all cases of variceal bleeding[1]. The Sarin classification system is a well-established system commonly used for classifying GV[1]. It is sub-divided into gastroesophageal varices (GOV1, GOV2), isolated GV (IGV1, IGV2)[2].

GOV1 are those EV, which extend into the lesser curvature of the stomach. GOV2 are those EV, which spread into the greater curvature. While IGV1 are those which are only seen in the fundus of the stomach. IGV2 are varices seen elsewhere in the stomach[1].

Classifying these varices is important as the treatment modalities depend upon the exact type and location[1].

I read with great interest the article by Deng et al[3], that recently got published in the World Journal of Gastroenterology, a commendable work by the authors, however, I had my reservations on some of the statements made by writers.

The declaration mentioned by the authors, “currently no consensus statement has been reached on the endoscopic treatment of GOV1” seems incorrect. The American Associations for the Study of Liver Disease (AASLD) guidelines of 2017 and 2023 have repeated mentioned the best possible treatment options that are available when treatment patients with GOV1 varices.

According to the AASLD guidelines of 2017, any bleeding that arises from the GOV1 varices should be managed with either endoscopic variceal ligation (EVL) or cyanoacrylate glue. While the latest AASLD guideline of 2023, states EVBL solely as the treatment of choice for GOV1 patients [4].

Furthermore, trans jugular intrahepatic portosystemic shunt (TIPS) has been suggested for GOV2 and IGV1, whereas cyanoacrylate glue (not yet approved in the United States) is advisable in those cases where TIPS is not feasible [5].

The proclamation by the authors that currently endoscopists practice modified sandwich method seems far from the truth, with the article cited by them also demanding conducting randomized control trials to ascertain the effectiveness and efficacy of the modified sandwich method[6].

It is worth mentioning that other non-cirrhotic causes which can lead to GV like extrahepatic portal vein obstruction, splenic vein thrombosis, inferior vena cava obstruction, were not included this study[7].

Additionally, the standard classification system used for GOV is either as small, those, which are less than 5 mm in size or as large, more than 5 mm[5].

Moreover, EVL has been mentioned incorrectly as endoscopy body ligator and not as endoscopy band ligator at a couple of places in the article.

Newer modalities for GV include endoscopic ultrasound (EUS) guided coil and sponge insertion have yet to make their place in the guidelines[8].

Nevertheless, I feel these points should be kept in mind for the readers as one of the most important aspects of hepatology has been touched in this article.